MEDICARE: DR. CALVIN ALEXANDER GRANT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	036111343	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	205786	OTHER	IL	PTAN IL MEDICARE DUPAGE COUNTY
3	205785	OTHER	IL	PTAN IL MEDICARE COOK COUNTY
5	P00638025	OTHER	IL	MEDICARE RAILROAD IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	1679551014	OTHER	IL	NPI
7	K47805	OTHER	IL	PTAN

General Provider Information

NPI Number	:	1679551014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CALVIN ALEXANDER GRANT M.D.

Provider Business Mailing Address
First Line	:	7808 W COLLEGE DR
Second Line	:	SUITE 1-NW
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1027
Country	:	US
Telephone Number	:	708-499-0123
Fax Number	:	708-499-0611

Provider Business Practice Location Address
First Line	:	7808 W COLLEGE DR
Second Line	:	SUITE 1-NW
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1027
Country	:	US
Telephone Number	:	708-499-0123
Fax Number	:	708-499-0611

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2006
Last Update Date	:	12/01/2009

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